US National Security and Global Health

31 Pages·2009·0.81 MB·English

U.S. National Security and Global
Health
An Analysis of Global Health Engagement
by the U.S. Department of Defense
CSIS CENTER FOR STRATEGIC &
INTERNATIONAL STUDIES
A Report of the CSIS Global Health Policy Center—Working Draft
1800 K Street NW | Washington, DC 20006
authors
Tel: [phone] | Fax: [phone] Eugene V. Bonventre
E-mail: [email protected] | Web: www.csis.org
Kathleen H. Hicks
Stacy M. Okutani
April 2009
CSIS CENTER FOR STRATEGIC &
INTERNATIONAL STUDIES
U.S. National Security and Global
Health
An Analysis of Global Health Engagement
by the U.S. Department of Defense
A Report of the CSIS Global Health Policy Center—Working Draft
authors
Eugene V. Bonventre
Kathleen H. Hicks
Stacy M. Okutani
April 2009
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Center for Strategic and International Studies
1800 K Street, NW, Washington, DC 20006
Tel: [phone]
Fax: [phone]
Web: www.csis.org
u.s. national security and

embedd global health: an analysis of

global health engagement by the

u.s. department of defense

Eugene V. Bonventre, Kathleen H. Hicks, and Stacy M. Okutani1

Executive Summary
Despite a broadening consensus that global health care efforts have an impact on national and
global security, the U.S. national security community’s efforts to address global health are weak
and uncoordinated. The 2006 National Security Strategy states that “development reinforces
diplomacy and defense, reducing long-term threats to our national security by helping to build
stable, prosperous, and peaceful societies.” While the U.S. government struggles to find the right
balance among the “three Ds” of defense, diplomacy, and development, the U.S. military has
increased its involvement in global health where it perceives the diplomacy and development to be
underresourced—or to achieve its own specific objectives. As efforts to renew the capabilities of
civilian agencies proceed, it is an appropriate time to step back and consider the role that the U.S.
Department of Defense (DoD) currently plays in global health, the impact of its health activities
on national and regional security, and the role it could play to support a newly balanced U.S.
foreign policy.
The intersection of global health and national security is usually discussed in terms of “threats”
and is best understood in the context of biosecurity, biosurveillance, and medical
countermeasures. Less well understood are the importance of health development in fragile or
conflict-affected states and the issue of health diplomacy in bilateral and multilateral relations.
Recent reports have highlighted the potential relevance of chronic disease, water and sanitation,
and access to basic health care on the stability, security, economic stability, and legitimacy of

Note: This is a working draft. CSIS welcomes your feedback. Please direct comments to the authors
at [email protected].

1 Eugene Bonventre is a senior associate with the CSIS Global Health Policy Center. Kathleen Hicks is
deputy undersecretary of defense for strategy, plans, and forces, and was a senior fellow in the CSIS
International Security Program at the time of this writing. Stacy Okutani is a senior analyst at the
Homeland Security Institute.
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governments.2 This paper attempts to frame health and security in terms of the “opportunities”
they present to advance both the United States’ objectives and the quality of global health care.
DoD plays a critical supporting role in the nation’s interagency response to human-made and
natural disasters. It provides unparalleled logistical, air transport, and sea transport capabilities, as
well as expeditionary medical personnel, to protect the health and welfare of populations affected
by crises. In addition, DoD’s extensive network of laboratories, technologies, therapies, and
medical expertise is a key component in the overall U.S. and international global health
surveillance and response system. Myriad DoD programs have an impact on global health, but
each has different and sometimes conflicting objectives. Some short-term DoD activities risk
undermining the longer-term objectives of civilian development agencies. Although, relative to
the huge overall DoD budget, the small amounts in DoD programs spent on global health make it
difficult to garner the attention of senior DoD leaders, these expenditures represent large sums to
developing nations and nongovernmental organizations (NGOs), which have pointed out that
much can be accomplished in global health with small monetary outlays.
In combat environments such as Iraq and Afghanistan, DoD has a clear responsibility to protect
the health of its forces. But it has been thrust into an unanticipated role in the reconstruction of
host-nation medical capability and infrastructure, given the relative lack of adequately resourced
expeditionary capacity among civilian U.S. government agencies. The counterinsurgency strategy
of “clear, hold, and build” requires a swift and agile entry of agencies that can build essential
services, including health, water, and sanitation, within a very small window of opportunity. But
civilian agencies are woefully underresourced, and aid mechanisms are complex, inflexible, and
uncoordinated. If U.S. civilian agencies are not sufficiently mobilized, or if their NGO
implementing partners are not willing to participate in such a “securitized” version of relief and
development efforts, then the military will fill perceived gaps. New civilian structures have been
created to plan and implement reconstruction and stabilization missions, without achieving a
consensus on the strategies required for health-sector reconstruction to reduce the risk that
conflicts will recur or ensuring that individual agencies play complementary roles. Civil-military
dialogue on these issues is vital, and it must take into account the voice of civil society and the
post-conflict nation itself.
The most controversial areas of DoD’s involvement in global health are diplomacy and
development. In both, DoD is best equipped to serve in a supporting role to NGOs and civilian
government agencies. Progress on creating an appropriate, fiscally responsible role for DoD in
these areas is hindered by the lack of a whole-of-government strategic approach and of productive
debate on the effect that a more integrated civil-military process would have on the NGO

2 National Intelligence Council, Strategic Implications of Global Health, ICA 2008-10D, December 2008; and
Institute of Medicine, The U.S. Commitment to Global Health: Recommendations for the New
Administration, 2009.
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implementing partners of civilian agencies. To better define and prioritize the duties and goals of
such involved agencies, including DoD, the U.S. government should take these steps:
(cid:131) Create a strategy for global health that balances the security dimension appropriately within a
holistic national and international approach and clearly articulates the role of global public
health within the U.S. national security strategy.
(cid:131) Create a global health security cooperation plan to guide DoD investments that build the
capacity of partner militaries’ public health, medical, and veterinary systems in a way that
complements the health development and health security efforts of civilian agencies and
multilateral partners.
(cid:131) Ensure that DoD’s global health actions support security and stability by improving
coordination between the undersecretary of defense for policy, the assistant secretary of
defense for health affairs, geographic combatant commands, and their subordinate agencies
and components.
(cid:131) Combine civilian and military disease surveillance and outbreak response capabilities, and
create a synergy between these activities and the public health systems capacity-building
efforts of U.S. government agencies.
(cid:131) Revise U.S. military training plans to support and complement building partner militaries’
public health and medical care capacities.
(cid:131) Create an integrated interagency assessment and evaluation system to measure both the health
and the security outcomes and effects of the interventions noted above.
These steps will require an expansion of resources of the State Department and the U.S. Agency
for International Development and strong political leadership from these agencies, as well as more
robust political will and support from Congress. But by taking these steps, the U.S. government
will become better able to meet its global health, foreign policy, and national security objectives,
without an expansion of the DoD’s budget or authorities.
Overview

Global health and U.S. national security are inexorably intertwined. “Global health” is
increasingly understood as a strategic approach to health promotion and disease prevention that
transcends national interests in an increasingly globalized, multilateral, and interdependent world.
Framing the issue of health this broadly requires consideration of safe water, sanitation, and
animal health, rather than medical care alone. The health of human and animal populations
overseas can affect nearly every aspect of Americans’ safety and prosperity—from trade to the
stability of foreign governments and populations, to the physical well-being of U.S. citizens at
home.
As shown by the cautionary example of how the severe acute respiratory syndrome (SARS) virus
reached Toronto by commercial airliner after the disease’s outbreak in China, protecting any
eugene v. bonventre, kathleen h. hicks, and stacy m. okutani | 3
country’s citizens depends on detecting outbreaks early and then quickly isolating them at their
origin. Therefore, developing strong national public health systems and global surveillance
systems benefits both the United States and other nations. Yet global health-related programs and
activities are not coordinated across the U.S. government nor within federal agencies or
departments. Programs are usually directed at a specific disease, and often with resources that are
not proportional to the disease’s prevalence or risk.
The recognition of a link between global health care and security has grown dramatically in recent
years. From World War II through the United States’ unilateral renouncement of its biological
weapons in 1969, the only diseases of security concern were those that were, or had the potential
to be, weaponized. That outlook changed in 2000 with the publication of The Global Infectious
Disease Threat and Its Implications for the United States,3 the first U.S. National Intelligence
Estimate “to consider the national security dimension of a nontraditional threat,” which
broadened the global health aperture beyond infectious diseases:
Highly publicized virulent infectious diseases—including HIV/AIDS, a potential influenza
pandemic, and “mystery” illnesses such as the 2003 outbreak of severe acute respiratory
syndrome—remain the most direct heath-related threats to the United States, but are not the
only health indicators with strategic significance. Chronic, noncommunicable diseases;
neglected topical diseases; maternal and child mortality; malnutrition; sanitation and access to
clean water; and availability of basic health care also affect the U.S. national interest through
their effects on the economies, governments, and militaries of key countries and regions.4
At the same time, concern over bioterrorism increased dramatically during the 1990s and even
further, following the September 11, 2001, terrorist attacks. The potential threat posed by
weaponized agents compounds the magnitude and range of health-related risks to national
security, although some experts believe that the response to bioterrorism threats has been out of
proportion to the actual threat.
DoD has long made significant contributions to science through military medicine, but its
strategic thinking about global health and security issues is evolving very slowly. Many defense
analysts view U.S. and Western efforts to improve the lives of populations considered at risk for
jihadist or other anti-American influences as particularly important. A prominent DoD report
recently noted that “in the battle for the narrative [between jihadists and the West], the United
States must not ignore its ability to bring its considerable soft power to bear in order to reinforce
the positive aspects of joint force operations. Humanitarian assistance, reconstruction, securing

3 National Intelligence Council, The Global Infectious Disease Threat and Its Implications for the United
States, NIE 99-17D, January 2000.
4 National Intelligence Council, Strategic Implications of Global Health, 5.
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the safety of local populations, military-to-military exercises, health care, and disaster relief are
just a few examples of the positive measures that we offer.”5
However, there is little direct evidence to suggest that health-sector activities contribute to the
long-term security, stability, governance, or legitimacy of fragile states.6 Furthermore, DoD’s
involvement in these “soft power” activities is not without controversy. Though few would argue
with DoD’s logistical support for the Office of U.S. Foreign Disaster Assistance after natural
disasters, civilian relief agencies have pointed out that because DoD’s assets are usually more
expensive than their civilian equivalents, military assets should be used only as a last resort and
also that to avoid militarizing disaster relief, these assets should remain under civilian control.
More controversial, however, is DoD’s growing peacetime civil-military health activity—which
DoD calls humanitarian assistance, but which more closely resembles what civilian agencies call
development. Such activities include well drilling, constructing or repairing clinics, and hospital
ship visits. DoD refers to these peacetime activities as “shaping” or “phase 0” activities because
they prepare its personnel for their combat and postcombat roles, which follow as phases 1 to 6.
Stewart Patrick laments, however, that “what DoD calls phase 0 is what we used to call foreign
policy.” A clear benefit would be gained by more precisely defining which of these peacetime
activities truly contribute to fulfilling the principles of security and stability, and by ensuring that
these often short-term efforts set the stage for the long-term development and conflict-mitigation
efforts of civilian agencies, rather than competing or interfering with long-range goals or
threatening the impartiality of nongovernmental organizations (NGOs) that claim to abide by
these principles.
DoD has also come to terms with the importance of rebuilding civil society following direct
combat operations. However unlikely U.S. involvement in new combat operations and post-
conflict operations may be, the fact remains that the United States is now involved in two major
reconstructive efforts; likewise, the possibility of involvement in other wars, even decades into the
future, cannot be completely eliminated. In 2005, the deputy secretary of defense issued a policy
directing military planners to prepare for military support for stability, security, transition, and
reconstruction operations with the same level of attention that they place on planning for combat
operations. Under this policy, DoD medical personnel must be “prepared to meet military and
civilian health requirements in stability operations.”7
Within the constraints of its existing authorities, missions, and expertise, DoD should be viewed
as a supporting agency in the pursuit of global health. DoD is at a strategic crossroads on global

5 U.S. Joint Force Command, The Joint Operating Environment, Center for Joint Futures, November 25,
2008, 39–40.
6 HLSP Institute, Health System Reconstruction: Can It Contribute to State-Building? Study commissioned
by the Health and Fragile States Network, October 2008.
7 Department of Defense Directive 3000.05, Military Support for Stability, Security, Transition, and
Reconstruction (SSTR) Operations, November 28, 2005.
eugene v. bonventre, kathleen h. hicks, and stacy m. okutani | 5
health—it is driven to do more in post-conflict settings and in biomedical research and
surveillance, indirectly involved in supporting health diplomacy and development, yet often
poorly received by and integrated with underresourced and understaffed civilian agencies and
poorly organized internally to rise to these demands. Its roles and responsibilities must be
clarified, and its conflicting policies and strategies must be resolved. Fears of securitization must
be critically examined in light of available evidence, not emotion, and DoD’s effects on a wide
range of stakeholders must be addressed, if it is to fulfill its potential as an important supporting
player in efforts to improve global health.
The U.S. Government’s Global Health Activities
A number of major U.S. government global health programs have an impact on national and
global security. These programs are listed in appendix A, which is intended to complement an
inventory of Global Health Funding being conducted by the National Security Council. Under
these U.S. programs, efforts to address potential health threats to U.S. security and leverage
opportunities fall into three basic categories. First, extensive U.S. government biodefense and
bioterrorism preparedness activities aim to prevent the spread of infectious diseases or biological
threats to Americans at home or U.S. service members overseas. These efforts are led by the
Department of State, Department of Homeland Security (DHS), Department of Health and
Human Services (HHS), and DoD. The National Institutes of Health (NIH) under HHS and the
Department of Agriculture lead U.S. government efforts to develop medical countermeasures to
the potential exposure of U.S. citizens and livestock to disease. Second, the State Department,
HHS, and other agencies engage in health diplomacy to improve bilateral and multilateral
relationships in support of U.S. foreign policy objectives. Third, the United States undertakes
programs to reduce poverty and improve the health of foreign populations in developing nations,
including those susceptible to radical, anti-Western influence. Support for governance and
economic development is in part intended to reduce the risk of political instability, mitigate the
effects of infectious diseases, avert conflict, and help post-conflict countries rebuild. The U.S.
Agency for International Development (USAID), the Millennium Challenge Corporation (MCC),
and the Office of the Global AIDS Coordinator, among others, provide funding for these
purposes.
Diplomatic and Development Efforts
In the last 10 years, issues such as the handling of the SARS outbreak in China, the USNS Mercy
hospital ship’s visits to Southeast Asia after the tsunami, and the donation of a mobile Army
surgical hospital to Pakistan after the Kashmiri earthquake have renewed debate on the
relationship between health and foreign affairs. David Fidler eloquently explains the various
6 | u.s. national security and global health
models for conceptualizing this relationship.8 For purposes of this paper, “health diplomacy” is
used to mean the influence of health activities on bilateral and multilateral relationships, and the
influence of bilateral and multilateral diplomacy on the U.S. global health agenda.
The major health diplomacy programs of the State Department are within the Office of
International Health Affairs and Biodefense in the Bureau of Oceans and International
Environmental and Scientific Affairs. The office “protects U.S. security and global economic
growth by promoting global health . . . and works with agencies throughout the U.S. government
to facilitate policy-making regarding environmental health, infectious diseases, health in post-
conflict situations and surveillance and response, bioterrorism and health security.”9 The Avian
Influenza Action Group is housed within this office.
Additionally, two State Department offices with global health responsibilities report directly to the
secretary of state. The Office of the U.S. Global AIDS Coordinator is the interagency leadership
and coordination body for the President’s Emergency Plan for AIDS Relief, which is designed to
reduce the transmission and impact of HIV/AIDS through support for prevention, treatment, and
care programs. The Office of the Coordinator for Reconstruction and Stabilization leads,
coordinates, and institutionalizes the U.S. government’s civilian capacity to help stabilize and
reconstruct societies in transition from conflict or civil strife, including the creation or restoration
of public health capabilities.
USAID is the U.S. government’s focal point for development assistance. Its key goals include
promoting human health and providing emergency humanitarian assistance.10 Its foreign service
officers work closely with NGOs, international organizations, and other partners around the
world. Since 2004, the MCC has also provided overseas development assistance. The MCC’s
mission is to reduce global poverty by promoting sustainable economic growth. It has several
programs aimed at improving the health of foreign populations and uses health indicators as a
means of measuring progress.

8 Nations and organizations have undertaken health activities for the purpose of influencing both bilateral
and multilateral relations, where achievement of any health objectives is secondary. Thus, Cuba deploys
medical doctors abroad, and Hamas and Hezbollah operate medical clinics and engage in post-conflict
health reconstruction. Likewise, however, diplomacy can influence health, such as when the World Health
Organization negotiated the Framework Convention on Tobacco Control. Still others frame health
diplomacy in terms of human rights, social justice, and equity. See D. P. Fidler, “Health as Foreign Policy:
Between Principle and Power,” Whitehead Journal of Diplomacy and International Relations (Summer/Fall
2005): 179–194.
9 See International Health and Biodefense, http://www.state.gov/g/oes/c1874.htm.
10 See, for example, USAID Primer: What We Do and How We Do It,
http://www.usaid.gov/about_usaid/primer.html.
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